Rush University College of Nursing
Pharmacology (NSG 511)
Unfolding Case Study Part One: The Patient with Hypertension
Pathophysiology Concepts:
Hypertension (primary, no discernible cause) and hyperlipidemia (LDL cholesterol especially) damage
the arterial endothelium and lead to atherosclerosis.
Atherosclerosis is a systemic disease of the major arterial systems: cerebral, coronary, and peripheral.
Atherosclerosis narrows the artery, in this case the coronary artery, and decreases myocardial oxygen
supply. This is complicated by anemia, which further decreases oxygen supply.
Pharmacotherapy is directed at controlling hypertension (HCTZ and CCB), treating hypercholesterolemia
(atorvastatin), and preventing a first cardiac atherosclerotic event (aspirin)
Case Presentation
Reason for the encounter: The patient is a 52-year-old peri-menopausal person who is at a primary care
clinic for a routine annual exam.
Vital signs: Interpret these



98.6-86-16-168/94 (RA) -99% (current visit); BMI: 32
97.6-80-20-150/92 (RA) – 99% (one year ago); BMI: 30
98.4-76-18-156/82 (RA) – 99% (two years ago); BMI: 28
History:




Medical: Irregular menses
Surgical: NA
Social: Lives with spouse, two teenage children; does not smoke, drinks occasionally.
Family: Mother deceased, COD stroke; father deceased, COD heart attack; sister alive, renal
insufficiency.
Labs: Place arrows up/down for values that are outside the range of normal and interpret the results.
BMP
CBC
Na
142 mOsm/L
WBC
9.8
K
3.9 mOsm/L
RBC
2.9
Cl
105
Hemoglobin
9
CO2
24
Hematocrit
27
BUN
15
MCV
68
Creatinine
1.2
MCHC
25
eGFR
53 mLs/minute
Platelet
220
FBS
136
1
Allergies: No known allergies
Med List:
Drug: Generic (Trade)
Acetaminophen (Tylenol)
Ibuprofen
Dose
500 – 1000 mg every 8 hours
prn
200-600 mg every 8 hours prn
Route
Oral
Indication
HA, pain, fever
Oral
HA, pain, fever
List four medical diagnoses that are evident from the case. Provide evidence.




Physical exam:
Constitutional: Appears well.
HEENT: Normocephalic; PERRLA, red reflex and vessels visible; canals clear, drums pearly gray; mucus
membranes moist, teeth in good repair; neck supple, thyroid not palpable.
Cardiac: Skin warm, distal pulses 2+, no edema; S1, S2, + S4, no murmur/rub.
Respiratory: Chest symmetrical, vesicular sounds in periphery, no crackles or wheezes.
Abd: Obese, no scars; BS + in four quadrants; percussive note tympanic; no masses.
GU: Deferred.
Extremities: Feet warm, no lesions, dorsalis pedis and posterior tibial 2+, no neuropathy.
Draw a concept map demonstrating the relationship between the diseases. Concept maps vary among
courses. Do not get hung up on that.



Circles
Below the circles data from the case to support the diagnosis
Use arrows to indicate cause and effect relationship between the medical conditions. A solid arrow
means the relationship is well established; a dashed arrow indicates a relationship that is possible.
2
Medical condition:
Medical condition:
Pt age and sex
Reason for
encounter:
Medical condition:
Medical condition:
3
The patient leaves her appointment with the following prescriptions.
Drug: Generic (Trade)
Ferrous sulfate
Hydrochlorothiazide
Nifedipine SR
Dose
324 mg daily
25 mg daily
30 mg daily
Route
oral
oral
oral
Indication
Iron deficiency anemia
Hypertension
Hypertension
1. The patient asks how a diuretic and calcium channel blocker will lower blood pressure. Look at the
blood pressure formula and think about how the drug works. Use the green highlighter to identify
which component of the BP formula the drug changes and in which direction (up or down).
Hydrochlorothiazide
𝐵𝑃 = (𝐻𝑅 𝑥 𝑆𝑉) 𝑋 𝑅
Nifedipine SR
𝐵𝑃 = (𝐻𝑅 𝑥 𝑆𝑉) 𝑋 𝑅
2. The patient asks what side effects she might expect based on these drugs in combination and each
drug individually.


Use Lexicomp to determine drug interactions.
Use notes and text to address each drug individually. Pick no more than three side effects based
on the drugs mechanism of action.
Side effects
HCTZ and nifedipine in combination
HCTZ alone
Nifedipine alone
3. When should the patient’s BP be re-evaluated and what is the goal BP (See lecture notes, Blood
Pressure Thresholds and Recommendations for Treatment and Follow Up)?


Re-evaluation: _____________
BP goal: _______________
To evaluate the patient’s risk for atherosclerotic cardiovascular disease the provider orders a lipid panel.
The results are listed below. Which type of cholesterol contributes to atherosclerotic disease?
LIPID PANEL
Cholesterol total
Triglyceride
HDL cholesterol
LDL cholesterol
265 mg/dL
100 mg/dL
26 mg/dL
170 mg/dL
4
The following medicines are added.
Drug: Generic (Trade)
Aspirin
Atorvastatin
Ferrous sulfate
Hydrochlorothiazide
Nifedipine SR
Dose
81 mg daily
20 mg daily
324 mg daily
25 mg daily
30 mg daily
Route
oral
oral
oral
oral
oral
Indication
Primary prevention, MI
Hyperlipidemia
Iron deficiency anemia
Hypertension
Hypertension
Look at p. 566 of text. This algorithm shows the major indications for statin therapy. They are: clinical
ASCVD, LDL-C > 190 mg/dL, diabetes, and 10 year ASCVD risk estimate. She does not meet the first
three criterion but she’s darn close.
4. Figure out her 10-year risk using the data provided and this risk calculator
http://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/. The case does not provide a
race or smoking history so make them up.
There are significant concerns about using race for risk assessment. Here's one example with heart
failure where being non-black increases the risk score and tilts treatment away from Blacks.
5. Serious adverse effects with atorvastatin are infrequent. Fill in the table below to remind yourself of
the adverse effects, relative frequency, patient symptoms, and lab testing (Use notes and text p.
571).
Adverse effect
Frequency
Symptoms
Lab evaluation
Myopathy
Hepatotoxicity
6. Aspirin is indicated for a variety of conditions including pain, fever, and antiplatelet effect. What is it
about the dosing and frequency of aspirin that makes it for primary prevention of MI and not for
pain or fever?
7. The patient asks if it matters whether she takes the medicines in the morning or evening and with
regard to meals. Think about the drugs, their mechanisms of action, potential adverse effects and
any additional information that might help provide a reasonable answer. For each drug, select only
one recommendation and provide a rationale.
Drug
Recommendation
Morning dosing
Evening dosing
With meals
Aspirin
Atorvastatin
Hydrochlorothiazide
Nifedipine SR
5
Unfolding Case Study Part Two: The Same Patient with ASCVD and Cardiac Ischemia
Pathophysiology Concepts:
Ischemic Heart Disease: Acute coronary syndrome
Oxygen supply (decreased due to atherosclerosis of coronary arteries) and demand (increased due to
hypertension and tachycardia). The imbalance leads to ischemia, injury, and if not corrected, myocardial
infarction.
Hemodynamics and their effect on myocardial oxygen demand
o
o
o
Preload: End diastolic volume
Contractility: Force of cardiac muscle shortening (contraction)
Afterload: Resistance to the ejection of blood
Mechanisms of clot
o
o
formation: Platelet aggregation (arterial) and activation of clotting cascade (venous)
dissolution: Activation of plasminogen
Pharmacology is directed at increasing myocardial oxygen supply (oxygen, aspirin) and reducing oxygen
demand (HCTZ and NTG to reduce preload, nifedipine to reduce blood pressure and afterload,
metoprolol to reduce contractility and heart rate) and increasing supply (alteplase to disintegrate
coronary artery thrombosis and heparin and warfarin to prevent recurrence of thrombosis)
Case Presentation
Reason for the encounter: The patient is now 57 years old and is seen in the Emergency Department for
episodes of indigestion, nausea, diaphoresis and chest discomfort that occur at rest and when active.
Vital signs in 15-minute intervals most recent first. Interpret these. What’s different compared to earlier
vital signs?



98.6-110-16-148/88 (RA) -99% (current visit); BMI: 35
97.6-100-20-144/86 (RA) – 99%; BMI: 35
98.4-102-18-156/86 (RA) – 99%; BMI: 35
History:




Medical: Post-menopausal; HTN; ASCVD; Diabetes mellitus type 2
Surgical: NA
Social: Lives with spouse; does not smoke, drinks occasionally.
Family: Mother deceased, COD stroke; father deceased, COD heart attack; sister alive, renal
insufficiency.
Labs: Place arrows up/down for values that are outside the range of normal and interpret the results.
BMP
CBC
Na
140 mOsm/L
WBC
9.0
6
K
Cl
CO2
BUN
Creatinine
eGFR
FBS
LIPID PANEL
Cholesterol total
Triglyceride
HDL cholesterol
LDL cholesterol
CARDIAC
Troponin I
5.1 mOsm/L
100
24
15
1.4
43 mLs/minute
100
150 mg/dL
60 mg/dL
30 mg/dL
85 mg/dL
RBC
Hemoglobin
Hematocrit
MCV
MCHC
Platelet
3
8.9
27
75
28
220
Thyroid Panel
TSH
1.2 uIU/mL
Diabetic panel
HA1C
Average glucose
6.8%
150
< 0.1 ng/mL
ECG: Sinus tachycardia; T wave inversion leads I, avL, V1-3; no ST segment elevation, no Q waves.
Allergies: No known allergies
Home Med List
Drug: Generic
Aspirin
Atorvastatin
Ferrous sulfate
Hydrochlorothiazide
Metformin
Nifedipine SR
Dose
81 mg daily
20 mg daily
324 mg daily
25 mg daily
1000 mg twice a day
30 mg daily
Route
oral
oral
oral
oral
Oral
oral
Indication
ASCVD prophylaxis
Hypercholesterolemia
Iron deficiency anemia
Hypertension
Diabetes mellitus type 2
Hypertension
1. What condition is this patient experiencing: stable angina or acute coronary syndrome? If ACS, is
she experiencing unstable angina, non-ST segment elevation myocardial infarction, or ST segment
elevation myocardial infarction? Provide rationale.
2. Provide evidence for each of the following:
a. Increased myocardial oxygen demand:
b. Decreased myocardial oxygen supply:
The patient is prescribed sublingual nitroglycerine 0.3 mg repeat x 1 and oral aspirin 325 mg dose x 1.
Her pain resolves and the ECG normalizes.
3. Match the medicine with the correct instructions by the nurse. There is only one correct instruction
for each pill.
Medicine
Nitroglycerine 0.3 mg SL
Instruction
Swallow this pill whole. Take it with a glass of water.
7
Aspirin 325 my oral
I’d like you to put this pill inside your mouth and next to your
cheek. Let it sit there until it dissolve.
I’d like you to put this on top of your tongue, let it dissolve,
and then swallow it.
I’d like you to put this under your tongue and let is dissolve.
Do not swallow it.
4. Nitroglycerin relaxes vascular smooth muscle via dephosphorylation of myosin (see text figure 54.2).
Its pain-relieving effect occurs because it dilates veins -> reduces venous return -> reduces preload > reduces contractility (whew!). Based on this fact, does nitroglycerine increase myocardial oxygen
supply or reduce myocardial oxygen demand? Explain your reasoning.
5. Aspirin in once daily doses is used for its antiplatelet effect in patients with ASCVD. ASCVD is a
disease of _______________ (arteries or veins). Vessels with atherosclerotic plaque trigger platelet
accumulation either due to turbulent blood flow or plaque rupture (see text fig 53.2). By preventing
platelets from accumulating, aspirin works by increasing myocardial oxygen supply or reducing
myocardial oxygen demand? Explain your reasoning.
6. Aspirin irreversibly binds to platelets. What’s the clinical significance of this finding?
Current vital signs and pertinent updates:
97.6-110-24-130/72-99%
The provider adds metoprolol 25 mg SR tablets take once a day.
7. Oral pills are often modified by the pharmaceutical industry for a particular purpose. I’ve listed
three common modifications. Match the modification to the correct statement.
Enteric coated
aspirin
Sustained
release
metoprolol
Immediate
release
morphine
The pill contains spheres that contain the drug. The individual spheres dissolve
at variable rates – some slowly and others more quickly – meaning the drug is
released throughout the day. Sustained release formulations are used to
reduce the number of pills needed per day. Dissolving these pills in water
before administering them destroys the modification with the patient getting a
24-hour dose at one point.
This formulation is used when a patient is experiencing an acute event and
needs immediate treatment.
Coated with a waxy substance to a. protect the stomach from drugs that cause
discomfort and b. protect the drug from exposure to stomach acid and pepsin.
Dissolving these pills destroys the modification.
8. The patient’s blood pressure was 130/72, yet the provider ordered metoprolol. Circle the answer
that completes the blanks.
8


Metoprolol is an _____________ (adrenergic/cholinergic) (agonist/antagonist). Metoprolol is
specific for ____________ (alpha/beta1, beta2) receptors. In this situation, metoprolol will lower
blood pressure (though not a first line drug for this purpose) and lower ______.
Circle the set of vital signs that indicate that metoprolol is working to reduce myocardial oxygen
demand? Provide an explanation.
o 98.4-76-128/74-95%
o 98.4-110-136/84-99%
o 98.4-100-122/82-95%
The patient symptoms recur (diaphoresis, indigestion, nausea, and chest discomfort) now with ST
segment elevation and troponin I of 2.3 ng/mL. She is transferred to the Cardiac Intensive Care Unit for
management of acute coronary syndrome: ST segment elevation myocardial infarction. (SIDE BAR: In
most settings a patient such as this would be sent to the Cardiac Catheterization Laboratory for a
percutaneous angioplasty intervention (PCI) and stent. However, because this is a pharmacology class,
we’ll focus on medication management.)
Medication Orders
Drug
Alteplase (tissue
Plasminogen
Activator)
Heparin
Dose
Route
Indication
100 mg over 1.5 hours. 15 mg bolus over 1-2
IV
ACS: STEMI
minutes, then infuse 50 mg/30 minute, then
infuse 35 mg/1 hour.
60 units per kilogram bolus, 12 units/kg/hour
IV
ACS: STEMI
infusion. Titrate to aPTT 50-70 seconds.
Nitroglycerin
5-10 mcg/minute titrate for pain relief. Hold if
IV
Acute cardiac
SBP drops below 90 or by more than 30 mmHg.
ischemia
Think about alteplase and heparin when looking at the image below. Keep in mind that the goal is to
degrade the coronary artery thrombosis and prevent its reformation. For every physiologic process
there is an opposing process and that’s certainly the case with clot degradation and formation. Heparin
prevents thrombosis (clot) formation by inactivating activated clotting factors. Alteplase causes clot
degradation (lysis) by activating plasminogen.
9
9. First, let’s have some fun with math! The patient weighs 176 pounds. Use dimensional analysis to
solve each calculation to the tenth place and do not round.
Vial
Premixed bag
Here’s the order for heparin: Give an IV bolus of 60 units/kg followed by an infusion of 12
units/kg/hour. Titrate to aPTT 50-70 seconds.
Calculate the bolus for heparin in mLs using the vial label. The answer is 4.8 mLs. Notice I solved to
the tenth place and did not round. A question very similar to this will be on the exam!
Calculate the infusion of heparin in mLs/hour using the premixed bag label. The answer is 19.2
mLs/hour. Notice I solved to the tenth place and did not round. A question very similar to this will
be on the exam!
10. The patient has received her alteplase, and thanks to you, also her heparin. She is now pain free
and the ST segment elevation has normalized. Consider each of the following hypotheticals and
respond to each question.



Alteplase has a thrombolytic duration of action of ~ one hour after completion of the infusion.
There is an order for placement of a peripheral intravenous catheter 15 minutes after
completion of the infusion. How should the nurse proceed?
The patient develops acute confusion and declining neurologic function. What complication has
occurred?
Four hours after the alteplase and with the heparin infusing the aPTT returns with a value of
110. How should the nurse respond? What about if the value was 30?
11. Heparin, an anticoagulant (emphasis not an antiplatelet or a thrombolytic), has many indications but
is either given subcutaneously or by bolus/continuous infusion. Think though these indications and
determine which administration route is likely. Provide your reasoning.
Condition
Route (bolus/infusion
or SC)
Reasoning
Acute cerebrovascular accident
Acute pulmonary embolus
Deep vein thrombosis
Deep vein thrombosis prophylaxis
10
The following adjustments were made to the patient’s medications: HCTZ and nifedipine stopped,
metoprolol and nitroglycerine (in two different formulations) continued, enalapril added.
Drug: Generic
Aspirin
Atorvastatin
Enalapril
Dose
325 mg daily
80 mg daily
20 mg daily
Route/schedule
Oral/AM
Oral/PM
Oral/AM
Ferrous sulfate
Hydrochlorothiazide
Isosorbide dinitrate
324 mg daily
25 mg daily
40 mg twice a day,
none after 8 PM.
1000 mg twice a day
25 mg daily
30 mg daily
0.3 mg prn
Oral AM
Oral
Oral/AM & PM
Indication
ASCVD prophylaxis
Hypercholesterolemia
Hypertension, at risk for
HF (stage A)
Iron deficiency anemia
Hypertension
Angina prevention
Oral AM & PM
Oral/AM
Oral
Sublingual
Diabetes mellitus type 2
Angina prevention
Hypertension
Angina treatment
Metformin
Metoprolol ER
Nifedipine LA
Nitroglycerin
Her morning assessment includes the following:
She is pain free and her physical exam is unremarkable. Vital signs: 99.4-82-20-140/76-95% (RA).
Labs: Place arrows up/down for values that are outside the range of normal and interpret the results.
BMP
Na
K
Cl
CO2
BUN
Creatinine
eGFR
FBS
CLOTTING
aPTT
138 mOsm/L
5.2 mOsm/L
98
24
15
1.4
43 mLs/minute
100
75
12. Let’s talk about enalapril. Complete the blank spaces by circling the correct answer in parentheses.
Enalapril is a(n) _______________ (BB, CCN, ACEi, ARB). Its beneficial effects are caused by blocking
the vasoconstricting effects of _______________ (angiotensin 2, aldosterone) and blocking
sodium/water reabsorption and potassium excretion effects of ______________ (angiotensin 2,
aldosterone). Based on this, we would reliably predict that enalapril will result in which of the
following (circle one of each pair): Lower BP or Raise BP, Lower blood volume or Raise blood
volume, Lower potassium or Raise potassium.
13. All medicines are administered. At noon her vital signs are: 98.6-64-16-120/64-94% (on room air)
and she has no complaints. Explain how these vital signs are an improvement on the prior set.
Don’t recite the numbers, rather explain the physiology principles.
11
She is scheduled for discharge the following day and follow-up with cardiac rehabilitation. Her morning
assessment includes the following:
Vital signs: 99.4-60-20-124/72-95% (on room air)
Labs: Place arrows up/down for values that are outside the range of normal and interpret the results.
BMP
Na
K
Cl
CO2
BUN
Creatinine
eGFR
FBS
CLOTTING
aPTT
138 mOsm/L
5.4 mOsm/L
98
24
15
1.4
43 mLs/minute
100
30 (heparin discontinued)
Wading through a lot of clinical information can be challenging, to say the least. Let’s focus on trends
over 24 hours and link each to one or more of the following drugs: enalapril, isosorbide dinitrate,
metoprolol
HR: 82 – 64 - 60
BP: 140/76 – 120/64 – 124/72
K: 5.2 – 5.4
Absence of chest pain.
If you could pick only one drug, which would be responsible for
lowering her heart rate?
If you could pick only one drug as a first line antihypertensive, which
would it be?
If you could pick only one drug, which would be responsible for
increasing her potassium?
If you could pick only one drug, which would be responsible for her
absence of CP?
The dose of enalapril is decreased and the patient is scheduled for afternoon discharge with the
following diagnoses: HTN; ASCVD; hypercholesterolemia, Diabetes mellitus type 2; Acute myocardial
infarction, renal insufficiency.
Pick one of the drugs in this case. Record yourself telling the patient about the drug using plain
language (6th grade). Make sure to address why the patient is getting the drug (indication for this
patient), what benefit the patient will experience, and instructions about how to take it. Here’s an
example.
“Aspirin is a commonly used medicine. You’re getting it to protect your heart from developing a blood
clot. You should swallow it whole and take it with food. That way it won’t bother your stomach.”
12
Unfolding Case Study Part Three: The Same Patient with Heart Failure and Atrial Fibrillation
Pathophysiology Concepts:
Heart failure reduced (left ventricular) ejection fraction. Treatment is threefold:



reduce symptoms of fluid volume excess (reduce preload),
make it easier for the heart to contract (reduce afterload),
delay disease progression.
A common complication of heart failure is atrial fibrillation. The atria (upper chambers of the heart
quiver rather than contract).
Pharmacology for heart failure is directed at reducing preload (furosemide), reducing afterload
(antihypertensives), and delaying disease progression (ACE or ARB, sacubitril/valsartan).
Pharmacology for atrial fibrillation in the context of heart failure is directed at increasing the force of
myocardial contraction and decreasing heart rate (digoxin).
Case Presentation
The patient is now 62 years old. She is experiencing worsening shortness of breath, cannot walk more
than a block without getting fatigued, has gained weight, and her shoes are tight. The provider advises
the patient to go to the Emergency Department. In the ED she sits in a high fowler’s position and is
laboring to breath.
Vital signs in 15-minute intervals with most recent first.



98.6-72-24-148/88-92% (on 2L/minute nasal cannula); 184#
97.6-100-28-144/86 (RA) – 89% (on room air); 184#
98.4-102-18-156/86 (RA) – 89% (on room air); 184#
History:




Medical: HTN; ASCVD; hypercholesterolemia, Diabetes mellitus type 2; myocardial infarction,
renal insufficiency.
Surgical: NA
Social: Lives with spouse; does not smoke, drinks occasionally.
Family: Mother deceased, COD stroke; father deceased, COD heart attack; sister alive, renal
insufficiency.
Home medicines: No known allergies
Drug: Generic
Aspirin
Atorvastatin
Enalapril
Dose
325 mg daily
80 mg daily
20 mg daily
Route/schedule
Oral/AM
Oral/PM
Oral/AM
Indication
ASCVD prophylaxis
Hypercholesterolemia
Hypertension, at risk for
HF (stage A)
13
Ferrous sulfate
Hydrochlorothiazide
Isosorbide dinitrate
Metformin
Metoprolol ER
Nitroglycerin
324 mg daily
25 mg daily
40 mg twice a day,
none after 8 PM.
1000 mg twice a day
25 mg daily
0.3 mg prn
Oral AM
Oral
Oral/AM & PM
Iron deficiency anemia
Hypertension
Angina
Oral AM & PM
Oral/AM
Sublingual
Diabetes mellitus type 2
Angina
Angina
Labs: Place arrows up/down for values that are outside the range of normal.
BMP
CBC
Na
140 mOsm/L
WBC
K
5.6 mOsm/L
RBC
Cl
100
Hemoglobin
CO2
24
Hematocrit
BUN
18
MCV
Creatinine
1.6
MCHC
eGFR
35 mLs/minute
Platelet
FBS
100
LIPID PANEL
Thyroid Panel
Cholesterol total
150 mg/dL
TSH
Triglyceride
60 mg/dL
HDL cholesterol
30 mg/dL
Diabetic panel
LDL cholesterol
85 mg/dL
HA1C
CARDIAC
Average glucose
Troponin I
< 0.1 ng/mL
Natriuretic peptide
2000 pg/mL
(BNP) (nl<125; HF > 900)
9.0
4
12
36
92
34
220
1.2 uIU/mL
6.7%
143
The normal troponin means she hasn’t had a heart attack, the elevated BNP means she has heart failure.
ECG: Sinus rhythm, widened QRS, tented T waves. No ST segment elevation/Q waves (confirming she is
not experiencing an acute ischemic event).
1. The ECG findings of a widened QRS complex and tented T wave are consistent with which lab
abnormality (circle one): sodium, potassium, creatinine, troponin, BNP?
Draw a picture of the electrocardiographic effect of increased serum potassium. Here’s a normal
electrocardiographic rhythm and a blank for the artist in the group!
Draw normal Ps, widened QRS, and tented Ts. Those are the
hallmarks of electrocardiographic hyperkalemia.
14
CXR: See side panel.
Echocardiogram: Dilated cardiac silhouette (see XRAY above),
thin ventricular walls, enlarged left ventricular chambers, and an
ejection fraction of 20% (EF = SV/EDV) (SV = stroke volume,
EDV = end diastolic volume).
In the Emergency Department the patient receives 20 mg of
furosemide by intravenous push and she diuresis 1500 mLs of
dilute urine. She receives a low dose of intravenous morphine sulfate
(reduces preload and relieves air hunger).
1. Provide three reasons that furosemide was selected over the home medicine, hydrochlorothiazide.
Heart failure reduced ejection fraction is characterized by cardiac
remodeling (thinning and fibrosis of muscle and enlarged chamber)
with reduced ejection fraction. Compensatory responses to
decreased cardiac output generally make the failing heart work
harder which generally worsens its decline.
Pharmacotherapy for HFrEF is directed at decreasing the work of
the failing heart and preventing remodeling.
2. Complete the table below using your knowledge of pharmacology!
Compensatory responses
Sympathetic nervous system activation
Activation of RAA system leading to cardiac
remodeling (dilation, thinning, fibrosis)
Fluid retention and increased blood volume
Drugs used to disrupt mechanism
And notice that the drugs you so wisely entered above coincide with the recommendations from the
ACC/AHA and the NYHA!
15
The next morning the patient’s assessment is as follows:
Vital signs: 98.6-72-18-122/76-96% (on 2L/minute nasal cannula); 178#
Physical exam:



Constitutional: Appears comfortable;
Heart/PV: Skin warm/dry, pulses 1+, lower extremity edema 1+ to mid-calf, nl S1, S2, +S3, II/VI
systolic murmur left sternal border
Pulm: Sitting up right, one pillow orthopnea throughout night, upper lobes clear
anterior/posterior, crackles right and left lower lobes.
Labs: Place arrows up/down for values that are outside the range of normal and interpret the results.
BMP
Na
K
Cl
CO2
BUN
Creatinine
eGFR
FBS
CARDIAC
Natriuretic peptide (BNP)
140 mOsm/L
5.0 mOsm/L
100
24
18
1.3
52 mLs/minute
115
1000 pg/mL
Here are her medications. Notice the indications have expanded. This is an important concept. Drugs
and indications are not static.
Drug: Generic
Atorvastatin
Aspirin
Enalapril
Dose
80 mg daily
325 mg daily
20 mg daily
Route/schedule
Oral/PM
Oral/AM
Oral/AM
Ferrous sulfate
Hydrochlorothiazide
324 mg daily
25 mg daily
Oral AM
Oral
Isosorbide dinitrate
40 mg twice a day,
none after 8 PM.
1000 mg twice a day
25 mg daily
0.3 mg prn
Oral/AM & PM
Indication
Hypercholesterolemia
ASCVD prophylaxis
Hypertension, HF (stage
C)
Iron deficiency anemia
Hypertension, HF (stage
C)
Angina
Oral AM & PM
Oral/AM
Sublingual
Diabetes mellitus type 2
Angina, HF (stage C)
Angina
Metformin
Metoprolol ER
Nitroglycerin
The patient is doing well, and the nurse is preparing for her discharge the following day. One additional
medication has been added. Entresto 49/51. Entresto is a combination of sacubitril and valsartan.
3. The nurse should clarify this order because Entresto contains a drug, _________________, that is
very similar in mechanism to the drug, _____________________, which she is already receiving.
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4. Sacubitril, one of the two drugs in Entresto, works to increase the natriuretic peptide response to
heart failure. This is beneficial because the natriuretic response: place up/down arrow or complete
the word.
____ diuresis
____ vasoconstriction
____ vasodilation
____ fibrosis
The patient is discharged on the following medications. Please note medication reconciliation
Drug: Generic
Aspirin
Atorvastatin
Enalapril
Dose
325 mg daily
80 mg daily
20 mg daily
Route/schedule
Oral/AM
Oral/PM
Oral/AM
Ferrous sulfate
Hydrochlorothiazide
324 mg daily
25 mg daily
Oral AM
Oral
Isosorbide dinitrate
40 mg twice a day,
none after 8 PM.
1000 mg twice a day
25 mg daily
0.3 mg prn
49/51 mg
Oral/AM & PM
Indication
ASCVD prophylaxis
Hypercholesterolemia
Hypertension, HF (stage
C)
Iron deficiency anemia
Hypertension, HF (stage
C)
Angina
Oral AM & PM
Oral/AM
Sublingual
Daily
Diabetes mellitus type 2
Angina, HF (stage C)
Angina
HF (stage C)
Metformin
Metoprolol ER
Nitroglycerin
Sacubitril/Valsartan
The patient follows up at her primary care clinic three days after discharge. She is still short of breath
though not as severely as prior to her admission. The nurse takes her vital signs and does a brief
physical exam:
Vital signs: 98.6; 105 (Irregular); 18; 90/60 sitting & 120/72 supine; SpO2 95%; 178#.
History and Physical exam:




Lightheaded when sitting/standing suddenly; senses heart “flopping” in chest; tired of being sick
all the time; sleeps with two pillows
Constitutional: Appears tired
Heart/PV: Skin warm/dry, pulses 1+ and irregular, lower extremity edema 1+ to mid-calf, nl S1,
S2, II/VI systolic murmur left sternal border
Pulm: Crackles posterior lower lobes right/left
The ECG shows atrial fibrillation, a common complication of heart failure that occurs in response to
stretching of the atria.
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The patient is referred to the hospital but declines admission because she would prefer to be treated at
home. The following adjustments are made to her medications:
Drug: Generic
Atorvastatin
Aspirin
Digoxin
Ferrous sulfate
Hydrochlorothiazide
Dose
80 mg daily
325 mg daily
0.125 mg
324 mg daily
50 mg daily
Route/schedule
Oral/PM
Oral/AM
Oral/AM
Oral AM
Oral
Isosorbide dinitrate
40 mg twice a day,
none after 8 PM.
1000 mg twice a day
25 mg daily
0.3 mg prn
49/51 mg 24/26 mg
Oral/AM & PM
Indication
Hypercholesterolemia
ASCVD prophylaxis
Atrial fibrillation/HF
Iron deficiency anemia
Hypertension, HF (stage
C)
Angina
Oral AM & PM
Oral/AM
Sublingual
Daily
Diabetes mellitus type 2
Angina, HF (stage C)
Angina
HF (stage C)
Metformin
Metoprolol ER
Nitroglycerin
Sacubitril/Valsartan
5. Answer each of the following:



What are the two indications for digoxin for this patient?
What is the likely rationale for discontinuing the isosorbide dinitrate?
What is the likely rationale for decreasing the sacubitril/valsartan?
The mechanisms by which digoxin works are complicated, to say the least. Here is how it works to
increase inotropy (look it up if you’re not certain of its meaning).
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1. Blocks Na/K pump
which starts a cascade of
events:
 Na can’t leave cell and
this blocks the
exchange site;
 Na can’t enter cell and
Ca can’t leave cell
2. Ca accumulates inside
cardiac myocyte.
3. Ca+actin+myosin ->
contraction.
The mechanism for decreased chronotropy is even more challenging so just memorize this for now:
digoxin decreases heart rate by increased vagal nerve stimulation (CN X originates in the CNS and
provides parasympathetic stimulation to the heart (i.e. slows it)) and by slowing conduction through the
AV node. Okay, if that’s more physiology than you care to deal with, just know it slows heart rate.
Digoxin is rarely used first line because it has a narrow therapeutic index and therapeutic range and
requires very careful monitoring.
6. What is the mathematical concept of narrow therapeutic index versus a wide therapeutic index?
Draw and image.
7. What is the mathematical concept of narrow therapeutic range? Draw an image.
Monitoring for digoxin effectiveness and toxicity is an essential part of nursing practice because it is a
dangerous drug. This patient is getting digoxin to slow the heart rate in atrial fibrillation and to increase
inotropy for her heart failure.
Before administering digoxin, the nurse must make sure there are no indications of accumulation or
toxicity.
8. Complete the following table.
Helpful Blood Work
Digoxin level
K
BUN/Cr
Helpful Cardiac
Findings
Heart rate
Helpful non-cardiac
findings
Gastrointestinal
Visual
Warning values
Rationale for checking
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9. The nurse is instructing the patient about the expected effects of digoxin. Match the nursing
instruction to digoxin’s mechanism.
Instruction
I’d like you to check your heart rate in the morning. Do this
placing your fingers on the inside of your wrist just below the
thumb. Count your pulse there. It should be b/n 60 – 100 per
minute
If you notice you are losing strength in your arms and legs,
please give us a call because we are probably going to have to
do some lab tests.
It’s important for you to get out and walk. I’d like you to walk
for at least 5-10 minutes every day without getting tired.
Digoxin mechanism
Positive inotropy
Negative chronotropic effect
Hypokalemia
Summary:
This unfolding case study emphasizes the pharmacology for a hypothetical patient who experiences
hypertension and atherosclerosis that progresses to ischemic heart disease/acute coronary syndrome
that progresses to heart failure reduced ejection fraction. The emphasis has been on pharmacologic
therapy. However, for each condition the nurse should also be aware of non-pharmacologic
interventions such as exercise, weight control, and healthy diet.
Although not a major emphasis in the case, it’s important to realize that her predisposition and then
development of diabetes mellitus accelerates her ASCVD. Further, her iron deficiency anemia, which is
essentially unaddressed, would be particularly problematic during her acute coronary syndrome/ST
segment elevation myocardial infarction because her oxygen delivery would be negatively affected
because her capacity would be low.
The order of events presented here is not uncommon but keep in mind that not all patients with
hypertension/atherosclerosis experience an STEMI and not all STEMIs lead to heart failure. These
critical, life- changing events may occur independently on one another.
Finally, people of different genders and races and socioeconomic status have different profiles. For
example,





premenopausal women experience an atherosclerotic benefit that disappears after menopause and
estrogen decline;
child-bearing women should avoid drugs that are passed to the fetus and have known
teratogenicity: ACEs, ARBs, and warfarin come to mind;
African Americans benefit more from diuretics and CCB than other antihypertensives;
Medication reconciliation is needed at every transition of care;
Drugs cost money – and usually the newer the drug the more costly it is. Here’s data from GoodRx
for some of the drugs for cardiovascular disease:
Drug
GoodRx Cost
Entresto (combo valsartan and
~ 500/60 pills
sacubitril)
Valsartan
~ 25/60 pills
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Metoprolol ER
Enalapril
Metoprolol
Apixaban
Warfarin
~ 20/60 pills
~22/60 pills
~5/60 pills
~444/60
~8/60
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